Transcript GRAPPA PsA Treatment Guidelines Establish Diagnosis of

GRAPPA Guidelines for PsA: Considerations
GRAPPA Guidelines Mission Statement: “To develop guidelines,
based upon the best scientific evidence, for the optimal treatment
of patients with psoriatic arthritis (PsA).”
Guidelines: “Systematically developed statements to assist practitioner
and patient decisions about appropriate health care for specific clinical
circumstances” Institute of Medicine
• More data needed on prognostic factors (e.g.for peripheral arthritis,
oligoarticular vs polyarticular; erosive vs non-erosive, +/- other features
such as axial, skin, entheses, etc) to optimize stratification
• PsA multifaceted: How appropriate is extrapolation of efficacy/safety
data, and hence treatment guidelines, from similar conditions (psoriasis,
AS, RA, etc)? Can we borrow aspects of screening, stratification,
monitoring?
• Guideline exigency driven by introduction of novel immunomodulatory
therapies, and their expense; with sensitivity to local factors, cultural
differences, economics, etc
• Systematic review of available evidence has been performed and
published; J Rheumatol July 2006
GRAPPA PsA Treatment Guidelines
Establish Diagnosis of Psoriatic Arthritis
Peripheral
Arthritis
Skin and
Nail Disease
Initiate
Therapy
Initiate
Therapy
NSAIDs,
IA steroids,
DMARDs
(MTX, CsA,
SSZ, LEF),
Biologics
(anti-TNF)
Topicals
PUVA/UVB
DMARDs
(MTX,CsA,etc)
Biologics
(anti-TNF, etc)
Axial
Disease
Dactylitis
Enthesitis
Initiate
Therapy
Initiate
Therapy
Initiate
Therapy
NSAID
PT
Biologics
(anti-TNF)
NSAID
Injection
Biologics
(anti-TNF)
NSAID
Injection
Biologics
(anti-TNF)
Reassess Response to
Therapy and Toxicity
How to Use a Clinical Practice Guideline.
Hayward et al (evidenced based working group). JAMA
1995;274:570-4 & 1630-2.
I.
Are the results of the study valid?
- Were all important options and outcomes clearly specified?
- Was an explicit and sensible process used to identify, select and
combine the evidence? To consider the value of different outcomes?
- Is the guideline likely to account for important recent developments?
- Has the guideline been subject to peer review and testing?
II.
What were the results?
- Are practical, clinically important recommendations made?
- How strong are the recommendations?
- What is the impact of uncertainty associated with the evidence and
the values used in the guidelines?
III. Will the results help me in caring for my patients?
- Is the primary objective consistent with your objective
- Are the recommendations applicable to your patients?
See also …Shiffman et al; Ann Intern Med 2003; 139:493
Evidence based? treatment algorithm for Peripheral PsA
Polyarthritis
Oligoarthritis
Monoarthritis
?
Early DMARDs
SSZ (A); LFN (A); MTX
(B), CyA (B)
?
Adequate therapeutic
trial of 2 DMARDs ?
Anti TNF alpha
Positive Response
Failed Response
NSAIDs (A) +/- IA
corticosteroids (D)
Respond
Attributes of Systematically Developed Guidelines
• Validity: How closely is the guideline linked to the available
evidence?
• Reliability: Would a different group of developers derive
similar guidelines with the same evidence?
• Reproducibility: Would different care-givers interpret and
apply the guidelines similarly in similar contexts
• Clarity: Are the guidelines unambiguous and precise?
• Documentation: Is the method of development transparent
and clearly stated?
• Multidisciplinary: Did the developers represent more than
one clinical orientation towards the clinical problems being
addressed?
PsA Treatment Guidelines Proposal
Committees
Peripheral
arthritis
Systematic
Reviews
Skin & Nails
Axial Dx
Dactylitis
Enthesitis
Guideline
development
and
consensus
by
committees
and patients
Vote by
GRAPPA
Committees
• Peripheral Arthritis
– E Soriano, N Mchugh, P Mease, F Behrens, M Lebwohl
• Skin & Nails
– H Boehneke, A Gottlieb, B Strober. D Fiorentino
• Axial
– P Nash. J Zochling, D Gladman
• Dactylitis
– P Helliwell, P Healy
• Enthesitis
– K de Vlam. A Adebadjo
Treatment Guideline Model
Peripheral arthritis (# joints, pain, function,
location, damage, etc)
+ skin and/or nails (severity. location, QOL)
+ axial disease (pain, function, QOL)
+ dactylitis (pain, location, function)
+ enthesitis (pain, location, function)
Mild
Moderat
e
Severe
Peripheral Arthritis
Ski
n
Enthesitis
Dactylitis
Spine
 1-3 tender and/or swollen joints
 No erosive disease on plain film
 Function not significantly impaired
<3%
BSA
None
None
 No sign or symptoms
of spinal inflammation
 Normal Schoeber
score and normal AP pelvis form
 5+ tender/swollen joints
 Normal x-rays but
Oligoarticularor polyarticular
disease that interferes w/ normal function
 Or less than 5 T/S joints but with erosions or JSN
on x-ray
>3%
And
<10
%
BSA
1-3 entheseal
sites inflamed
1-3
inflamed
digits
Inflammatory back pain with a
normal
AP pelvis film
 >5 tender /swollen joints
w/ evidence of joint damage on exam
 Arthritis mutilans
 Oligo-or polyarticular
disease that limits ADLs
>10
%
BSA
 >3 sites
 Entheseal
involvement in foot
that
prevents
ambulation
 Tendon rupture
 >3
inflamed
digits
 Evidenc
e of
ankylosis
in
a dactylitic
joint
Symptomatic
inflammatory back
pain with radiographic
changes on plain film